It’s hard to contemplate “conservative treatment” in the case of a revised total knee arthroplasty (rTKA) with extensive instrumentation that needs a reoperation due to periprosthetic joint infection (PJI), because all the treatment options in that scenario are pretty complex. In the January 6, 2021 issue of JBJS, Barry et al. report on a retrospective review of 87 revisions of extensively instrumented rTKAs that found that irrigation and debridement (I&D) with chronic antibiotic suppression was as effective as 2-stage exchange in preventing another reoperation for infection—and more effective in terms of maintaining knee function.
The average follow-up of the cases studied was 3.2 years, and the authors carefully defined “extensive instrumentation.” Among the 56 patients who were managed with I&D and suppression and the 31 who were managed with the initiation of 2-stage exchange (average age in both groups approximately 67 years), no significant differences were found in the rates of reoperation for infection or mortality. However, 9 of the 31 patients (29%) in the 2-stage group never underwent the second-stage reimplantation. Among those 9, 3 died prior to reimplantation and 2 underwent amputation due to failure of infection control.
Moreover, at the time of the latest follow-up, a significantly higher percentage of patients in the I&D group were ambulatory (76.8% vs 54.8% in the 2-stage group) and were able to functionally bend their knee (85.7% vs 45.2% in the 2-stage group). The authors surmise that these 2 findings are related to the soft-tissue damage and bone loss that typically occur during stage-1 removal of rTKA components.
Barry et al. conclude that in similar situations “deviating from the so-called gold standard of 2-stage exchange and accepting the modest results of I&D may be in the best interest of the patient,” as long as there are no loose implants in the existing construct. But the “sobering” mortality rates in the study (39.3% in the I&D group and 38.7% in the 2-stage group) remind us that this clinical scenario is extremely challenging for patients and surgeons, no matter which option is selected.
Click here to view an “Author Insights” video about this study with co-author Jeffrey Barry, MD.
No consensus has emerged yet regarding the best prosthetic construct with which to manage patients who require revision surgery for dislocation after a total hip arthroplasty (THA). But in the December 2, 2020 issue of The Journal of Bone & Joint Surgery, Hoskins et al. add insight into that question by tapping the Australian Orthopaedic Association Total Joint Replacement Registry to analyze which of 4 first-revision component constructs led to the fewest second revisions.
Among the 1,275 THAs that were revised once for prosthesis dislocation, 203 hips went on to have a second revision, with dislocation being the most common cause for re-revision. The authors studied the second-revision THAs in 4 prosthetic categories: standard-sized femoral heads, large-sized femoral heads, dual-mobility heads, and constrained acetabular liners. The rate of all-cause second revision was significantly higher in the standard-head group when compared with the constrained-liner group. But in the 91 cases of second revisions for dislocation, the standard head showed significantly higher second-revision rates than any of the other 3 constructs. There was no statistically significant difference in rates of second revision between those 3 non-standard articulations
The authors discuss dual-mobility heads at some length, asserting that “caution should be exercised in their routine use, particularly in younger and active patients.” They note that the constrained liner was the “only articulation to show a difference when compared with standard-head THA for both all-cause revision and revision for a subsequent diagnosis of dislocation,” but they observe that impingement and acetabular component loosening are common concerns with constrained liners.
Despite these caveats, it seems clear from this data that the choice of articulating surface for either a first or second revision THA due to dislocation should probably exclude standard head sizes. Calling for longer-term data on all 3 alternative constructs studied here (the follow-up periods were different for all 4 articulations), the authors emphasize that “surgeons should [also] look beyond articulating surfaces”—to surgical approach, component orientation, and patient factors such as soft-tissue quality—in the effort to reduce the burden of THA dislocations.
We recently celebrated Veteran’s Day with the annual tradition of rightfully honoring the men and women who have served in the Armed Forces. After their active duty ends, servicemembers are eligible for care in Veterans Health Administration (VHA) hospitals around the nation. The VHA is a “closed” medical system that affords ample opportunity for population-based research.
In the November 18, 2020 issue of The Journal, Bendich et al. utilized VHA data to compare revision rates after primary total knee arthroplasty (TKA) among veterans treated with antibiotic-laden bone cement (ALBC) or plain cement. Although results of similarly designed studies focused on this question have been equivocal, antibiotic-laden cement seems to be especially effective at preventing infection in higher-risk populations, which is what the US veteran population is considered to be.
The researchers identified 15,972 primary TKAs that were implanted using Palacos bone cement between 2007 and 2015. Approximately 70% (11,231) of those cases used cement mixed with gentamicin, while 30% (4,741) utilized plain bone cement. The authors found similar patient demographics among patients treated with ALBC and those treated with plain cement, but ALBC was used more frequently in patients with higher comorbidity scores.
Overall, utilization of ALBC increased from 50.6% of the cases in 2007 to 69.4% in 2015. At a follow-up of 5 years, ALBC TKAs had a lower all-cause revision rate (5.3%) than plain-cement TKAs (6.7%) and a lower rate of revision for infection (1.9% compared to 2.6%). Even after multivariable adjustments to account for patient, surgical, and hospital factors, these revision-rate differences remained.
Bendich et al. also found that 71 TKAs needed to be implanted with ALBC to avoid 1 revision TKA. With a cost differential of $240 per case for ALBC, I think spending $17,040 ($240 × 71) is more cost-effective than 1 revision TKA, although a formal cost analysis is warranted.
In the interest of full disclosure, as an active-duty US Air Force officer, I am inherently biased, but I feel that no cost is too great to improve the health of our veterans. The authors review arguments against using ALBC, such as a theoretical risk of poor cement mechanical properties and systemic toxicity, but the findings of this study suggest that cement with antibiotics enhances treatment outcomes among these US heroes.
Click here to view the “Author Insight” interview about this study with co-author Alfred Kuo, MD, PhD.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Lower-extremity joint replacement is quite well-advanced, thanks to a high incidence of disabling osteoarthritis and a 40-plus-year history of development in hip and knee prostheses. Additionally, during the last 5 to 10 years, we have made progress in prosthetic design and reliable surgical techniques for the ankle. In the upper extremity, we have a similar 4-decade development history with anatomic shoulder replacement and now 10-plus years with increasingly reliable reverse total shoulder arthroplasty.
However, techniques for elbow and wrist arthroplasty have been much slower to develop, due to lower incidence of pathology, the unique functional demands on these joints, and prosthetic-design and fixation issues. Still, the Conrad-Morrey family of implants has provided reliable elbow prostheses for more than 20 years. Meanwhile, the indications for elbow arthroplasty have narrowed to inflammatory arthritis and distal humeral fractures and nonunions in patients with lower functional demands. Unfortunately, failure of fixation, infection, and bone resorption do occur after primary elbow arthroplasty; consequently, a small but growing number of patients face revision elbow arthroplasty.
In the November 18, 2020 issue of The Journal, Burnier et al. report the results of revision elbow arthroplasty using a proximal ulnar allograft-prosthetic composite to compensate for missing ulnar bone stock and triceps tendon insufficiency. They clearly explain the surgical technique and report their results among a 10-patient cohort, including details of the 6 cases that required reoperation.
JBJS will continue reporting results of revision joint arthroplasty because members of the orthopaedic community have to manage these very complex cases, and this type of information is helpful to guide treatment decisions and patient expectations. Equally important is the positive impact this information has on further development of surgical techniques and prosthetic designs. Close examination of failure is the fuel for innovative improvement.
Marc Swiontkowski, MD
In the October 7, 2020 issue of The Journal, Du et al. report on a multicenter database-derived cohort of 167 patients with early-onset scoliosis treated with traditional growing rods and followed for ≥2 years after “final” fusion. These researchers report that 19% of those patients required a repeat surgery following fusion, most commonly for surgical-site infection and anchor-site failure. Multivariate analysis of risk factors for reoperation following final fusion revealed the following:
- Curve progression requiring revision surgery during the spine-lengthening process
- The number of levels spanned with the growing rods
- The duration of treatment
Du et al. report these results without spin in a way that is most useful for surgeons who are considering using these implants in their armamentarium. This is the way all new technology, especially complex advances in surgical care, should be reported.
Orthopaedic implants and instruments continue to evolve, almost always toward more sophisticated digital technology, complex engineering, and more numerous moving parts. The advent of magnetic growing rods for treating early-onset scoliosis is just one example. Often such advances are reported on by surgeons who are conflicted by personal and financial interests in the technology. This leads to all manner of potential bias–indication bias, reporting bias, selection bias, and detection bias to name just a few. Readers should evaluate this type of data with a high degree of suspicion.
What we need throughout orthopaedics are more multicenter, multisurgeon, “deconflicted” cohort studies and clinical trials. When such rigorous studies are conducted to investigate “high-tech” growing rods in patients with early-onset scoliosis, I will not be surprised if researchers find the same risk factors for reoperation after fusion that Du et al. found.
Marc Swiontkowski, MD
Acetabular components for primary total hip arthroplasty (THA) made with ultraporous surfaces were developed to enhance osseointegration and biological fixation. In the July 1, 2020 issue of The Journal of Bone & Joint Surgery, Palomaki et al. report on a registry study that suggests that implant survival with these components over an average follow-up of 3.6 years is not so “ultra.”
The authors evaluated >6,000 primary THAs that used a Tritanium ultraporous cup and >25,000 THAs that used a conventional cup, all performed between 2009 and 2017. When they compared the two groups for revision for any reason, the 5-year Kaplan-Meier survivorship of the Tritanium group (94.7%) was inferior to that of the conventional-cup group (96.0%). When revision for aseptic loosening was examined, the 5-year survivorship was also inferior for the Tritanium group (99.0%) compared with the conventional group (99.9%). Regression analysis revealed that the Tritanium group had a much higher risk of revision for aseptic loosening 2 to 4 years after surgery (hazard ratio, 11.2; p <0.001). Interestingly, these survivorship and risk-of-revision differences disappeared when the authors analyzed data for the period from May 15, 2014 to December 31, 2017–when the registry was updated to include patient BMI and ASA-class data.
The authors cite several caveats that readers should apply to these findings. The registry did not capture radiographic findings for these patients, so potentially relevant imaging data could not be analyzed. And, despite the database upgrade in 2014, there was a dearth of available data on patient comorbidities. Finally, wide confidence intervals for some of the hazard-ratio calculations suggest the need to confirm revision-risk findings with further research.
Limitations notwithstanding, the study by Palomaki et al. suggests that the performance of ultraporous cups may not meet the hopes and expectations of hip surgeons and their patients.
These operations were performed by a group of fairly experienced surgeons who averaged >14 UKAs per year, although a commonly used threshold for a “high-volume” UKA surgeon is >15 procedures per year. The cumulative revision rate of 14.2% over 8.7 years, the 5-year Kaplan-Meier survival rate of 88%, and the 10-year survival rate of 70% found by Kazarian et al. are disturbing. Using revision as an endpoint may be problematic because some surgeons are quick to revise a UKA when the radiographic evaluation of component placement is not perfect. Still, this study demonstrates that radiographically determined alignment and overhang “outliers” and “far outliers” had a significantly increased risk of implant failure, compared with patients with good alignment and overhang.
This study did not include UKAs that used computer-assisted methods, but it seems safe to conclude that computer-assisted component placement would be more reliable than “eyeballing,” especially among surgeons with less-experienced eyes. Based on this and other recent studies, I think a controlled trial comparing the functional outcomes and revision rates of UKAs performed with and without computer assistance is warranted.
Marc Swiontkowski, MD
Editor’s Note: Click here to read the JBJS Clinical Summary on Unicompartmental Knee Arthroplasty.
Time is an enemy of all orthopaedic implants, just as it is the bane of native joints. It is therefore helpful to accurately measure how long and well specific implant types last. That is what Kim et al. have done with their 19-year follow up of 90 patients (107 knees) who underwent total knee arthroplasty (TKA) with a constrained condylar knee prosthesis. Their findings appear in the April 15, 2020 issue of The Journal of Bone & Joint Surgery.
Knee arthroplasty surgeons often choose constrained prostheses to improve joint stability in patients with ligament dysfunction, and the typically longer stems of these implants can also compensate for poor bone stock. Kim et al. evaluated the same patient population (mean age of 65 years; mean BMI of 26.9 kg/m2) that they reported on in an earlier study, finding the following outcomes after a mean follow-up of 19 years:
- 96% survival in terms of mechanical failure
- 91% survival in terms of reoperation for any reason
- Patient-reported outcome scores that remained significantly improved from pre-revision values
- Only 1 knee with osteolysis around a component
Among the few knees that required re-revision, 5 such operations were performed due to aseptic loosening and 4 due to infection. The authors note that these very good long-term results are similar to those in previous studies of revision TKAs using various implant types. Kim et al. attribute these findings to several possible factors:
- Low prevalence of comorbidities, including obesity, among the patients
- Excellent surgical technique, including good cementing and correct flexion and extension gaps
- Use of compression-molded polyethylene
Computer-assisted surgery (CAS) for total knee arthroplasty (TKA) has become popular largely based on claims that the technology improves accuracy of component positioning and alignment. Theoretically, that leads to superior patient-reported outcomes. However, the use of CSA has not reliably yielded improvements in implant survival or clinical outcomes. A large registry study by Roberts et al. in the April 1, 2020 issue of The Journal sheds additional light on this perplexing question.
An earlier study by the same author group used data from the same New Zealand Joint Registry and showed no difference in functional outcomes or implant survival between TKAs performed with and without CAS.1 However, that study did not account for the potential bias introduced by surgeons who use CAS only for complex cases.
In this study, Roberts et al. analyzed data from 2 carefully selected groups of surgeons: those who used CAS in 90% of their TKAs (“routine CAS” surgeons) and those who used CAS in <10% of their TKAs (“routine conventional” surgeons). Further limiting their analysis to surgeons with >50 TKAs recorded in the registry between 2006 and 2018, Roberts et al. identified 25 “routine CAS” surgeons and 22 “routine conventional” surgeons. This allowed a comparison between 9,501 TKAs performed by routine CAS surgeons and 7,672 TKAs performed by routine conventional surgeons. While analyzing revision rates and Oxford Knee Scores (OKS) at 6 months, 5 years, and 10 years, the authors also controlled for confounding variables such as age, body-mass index, and implant type.
With a mean follow-up of 4.5 years, the authors found a revision rate per 100 component-years of 0.437 in the group operated on by routine CAS surgeons, compared to a mean 4.9-year revision rate of 0.440 in the group operated on by routine conventional surgeons (p=0.724). When stratifying outcomes of patients <65 years old, the authors again found no statistical difference in revision rates. They also found no between-group differences in OKS within the full and <65 cohorts at 6 months, 5 years, or 10 years.
The findings prompt the authors (and I) to wonder whether continually improving design and durability of modern implants make it difficult to discern any advantage from computer assistance in implant positioning.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
- Roberts TD, Clatworthy MG, Frampton CM, Young SW. Does computer assisted navigation improve functional outcomes and implant survivability after total knee arthroplasty? J Arthroplasty. 2015 Sep; 30(9)Suppl: 59-63.
Orthopaedic surgeons work hard to find good alternatives to total hip arthroplasty (THA) in patients <50 years old. That’s because the high functional demands and longer remaining lifespan in these patients can result in excessive wear of the bearing surfaces and loosening of the components—both of which have been documented in multiple publications. But what happens when THA is the most viable solution for a posttraumatic or congenital hip problem in a very young patient because arthrodesis or other osteotomies are not feasible?
In the March 18, 2020 issue of The Journal, Pallante et al. report medium-term outcomes of THA in 78 patients who were ≤20 years of age at the time of surgery, with follow-ups ranging from 2 to 18 years. The findings included the following:
- 10-year survivorship for reoperation of 95.0%
- 10-year survivorship for revision of 97.2%
- 10-year survivorship for complications of 89.5%
Overall, the linear articular wear averaged 0.019 mm/yr in the ceramic-on-ceramic, ceramic-on-highly cross-linked polyethylene, and metal-on-highly cross-linked polyethylene bearings studied, and the average modified Harris hip score in the cohort was 92.
However, despite these impressive clinical and survivorship outcomes, I advise orthopaedists not to lower their resistance to performing THA on these very young patients, many of whom present with hip problems caused by deforming conditions such as Legg-Calve-Perthes disease. We really need 30 to 40 years of outcome data to truly understand what happens with function, revision rates, and wear characteristics in this population. Having said that, I am confident that this group from Mayo will continue reporting on this patient cohort at 5- to 10-year intervals, so that the worldwide orthopaedic community can keep learning from this experience.
Marc Swiontkowski, MD